Who can modify, delay and deny requests for treatment?

• A. Certified physician
• B. Licensed physician's assistant or nurse
• C. Licensed medical provider in that speciality
• D. Claims adjuster

Answer: (C)

The ability to modify, delay, or deny a treatment request rests with a licensed medical provider who has expertise in the patient’s specific condition. In a self‑insurance utilization process, decisions about medical necessity and appropriateness must come from someone who understands the relevant clinical standards and guidelines for that specialty. A licensed medical provider in that specialty is equipped to evaluate evidence, weigh risks and benefits, and determine what is medically necessary and safe. They can approve, adjust, or deny the requested treatment based on those clinical criteria.

Non-clinical staff, like a claims adjuster, handles payment and administrative issues and is not responsible for medical necessity determinations. While a physician is certainly qualified, the decision should come from a provider with the appropriate specialty to ensure the choice aligns with specialty-specific standards.